TY - JOUR
AU - Licina, Derek
AB - global health, global health engagement, medical, security cooperation, national security, medical readiness The Department of Defense (DoD) views Global Health Engagement (GHE) as a strategic enabler directly supporting U.S. national security.1 This is achieved when the Military Health System leverages Joint health capabilities to directly support the Combatant Command (CCMD) Theater Campaign Plan objectives. When properly conducted, GHE strengthens relationships, builds capacity and improves interoperability with Partner Nations. For GHE to fully realize its strategic potential, practitioners must have standardized processes and tools for execution at the tactical and operational levels. Unfortunately, teams conducting GHE activities are frequently challenged by the lack of standardized approaches and the related paucity of products to support operational and tactical. This gap places an excessive burden on subject matter experts to develop ad-hoc materials often resulting in disjointed products within and across the Services that may misalign, or worse undermine, the strategic objectives they seek to support. The current resource burden associated with creating and recreating GHE materials is considerable and comes with significant additional opportunity cost, detracting from other competing mission priorities. Moreover, without a framework in place, it becomes nearly impossible to evaluate program performance and effectiveness. In many instances, time is wasted, engagements suffer, partner participants are left confused, local capabilities fail to improve, and interoperability is not attained – in other words, the full potential of GHE is not realized due to clutter, discordance, and unnecessary difficulty. One solution is to provide GHE practitioners with Playbooks and Standardized Engagement Packages (SEP) to systematically align GHE tactics with CCMD objectives. In doing so, the Military Health System can more effectively support the overarching National Military Strategy and measure the impact of achieving these objectives. PLAYBOOKS: AN OPERATIONAL APPROACH The U.S. Army is developing Medical Functional Area Playbooks to improve the quality of GHE execution.2 Built around doctrinal health capabilities such as casualty management and medical logistics, the playbooks set forth a roadmap to guide multi-year engagements that transfer knowledge of a specified capability to partner nations over time. This longitudinal crawl-walk-run approach relies on a series of engagements whereby each successive mission incrementally builds upon and reinforces prior capacity enhancement efforts. The playbooks set the conditions for enhancing medical functional areas leading to improved health outcomes; while building relationships and achieving strategic objectives through persistent engagement. To achieve these ends, effective GHE activities rely on an accurate assessment of a partner’s current level of medical functional area capability and capacity. This is accomplished by leveraging the playbook’s Doctrine, Organization, Training, Material, Leadership and education, Personnel, Facilities, and Policy (DOTMLPF-P) assessment scorecard. The assessment allows partner and DoD participants to determine the starting point and desired endstate of engagement along specific medical functional area lines of effort. The assessment provides a path to prioritize efforts and guide the appropriate level of information to exchange during initial and subsequent engagements, until the desired outcome is realized. As a cyclical process, DOTMLPF-P assessments are repeated to monitor performance, measure effectiveness, and inform future policy decision making. Ideally, playbooks should be built around Military Health System capabilities which benefit the U.S. and its partner, enhance understanding of unique military issues, and nest within international and U.S. government health programs.3,4 These capabilities should enable partners to deliver suitable solutions to local health concerns; which could have broader economic and security implications. Through the use of standardized playbooks, the Military Health System can demonstrate to security cooperation stakeholders (e.g., CCMDs and U.S. Embassy country teams) how investing in medical functional areas assists in achieving strategic security objectives. STANDARDIZED ENGAGEMENT PACKAGES: A TACTICAL TOOL Playbooks provide an operational approach to GHE, but they must be supplemented with Standardized Engagement Packages (SEPs) to support medical practitioners in the field. SEPs are comparable to programs-of-instruction that equip practitioners with ready-to-use content to execute their tactical and operational level engagements (e.g., subject matter expert exchanges). For example, the U.S. Army Veterinary Services developed a Food Protection Playbook comprised of three SEPs, each containing approximately 40 h of educational content. The first SEP contains information on basic food safety (crawl), the second SEP is focused on more advanced scientific principles of foodborne hazards (walk), and the third SEP is designed to transfer a high-end, field-based capability (run). In essence, these packages support GHE practitioners with standardized and validated educational content the same way programs-of-instructions support Service training institution faculty with Lesson Plans. Additionally, subject matter experts build SEPs by identifying enabling and terminal learning objectives and assembling the essential content, practical exercises, and hands-on activities to achieve the desired effect. Ideally, package design should leverage pre-existing military medical training institution content and training aids. However, simply cutting-and-pasting existing products into SEPs is not sufficient. Alignment with current best practices is critical to creating value-added medical functional area playbooks. Mirroring current trends in U.S. Army training, SEP designers should stress adult and experiential learning models, superseding traditional didactic training (andragogy over pedagogy). PowerPoint-based presentations should minimize verbiage in favor of visual images. Military jargon, U.S. standards, and DoD references should be supplemented with international standards and professional norms where feasible (e.g., World Health Organization and SPHERE5). Culturally inappropriate material must be excluded. SEP designers and developers must recognize their primary customer is the U.S. medical practitioner and by extension, the partner. Standard engagement packages should be viewed as a library of material that can be easily accessed by individuals tasked to conduct GHEs, offering trainers material to draw from and tailor to meet mission specific requirements. Therefore, SEPs should err on the side of excess information, recognizing that they will be edited and refined as needed. CASE STUDIES USING THE FOOD PROTECTION PLAYBOOK AND SEPS Over the past 12 mo, U.S. Army Veterinarians developed and tested a Food Protection Playbook and associated SEPs in support of U.S. Central Command (USCENTCOM), U.S. Pacific Command (USPACOM), and U.S. Southern Command (SOUTHCOM). In SOUTHCOM, the veterinarians shared food protection knowledge and experience with their Chilean military counterparts. The exchange focused on food safety procedures in austere environments to prepare Chilean military forces for an upcoming United Nations Peace Keeping Operation in the Central African Republic.6 The mission in USPACOM discussed food protection in the context of the Global Health Security Agenda, strengthening the capacity of the Bangladesh Armed Forces to mitigate food and waterborne disease outbreaks. In USCENTCOM, a Joint U.S. military medical team executed an operational preventive medicine course in Kazakhstan to assist their military in establishing a commensurate course within their military medical training school. All three missions leveraged the same Food Protection SEPs, highlighting the value of playbooks and the ability for standardized products to support a wide variety of force health programs. Upon completion of the three engagements, analysis revealed strengths, weaknesses, opportunities and threats (SWOT) related to the use of SEPs. On the positive side, SEPs enabled GHE practitioners to focus efforts on mission execution versus mission preparation. By providing a framework and standardized content, the packages served as the starting point, tailored by the practitioner in support of each mission based upon participant needs. The SEPs were easily adapted to meet unique technical and cultural needs across CCMDs, empowering subject matter experts to provide the most relevant information within a standardized platform. Playbooks and SEPs can enhance more than just the quality of GHE activities. They can also help the DoD scale-up U.S capacity by impacting both the supply-side and demand-side of health engagement. By making SEP libraries readily accessible to GHE practitioners assigned across the globe, the DoD increases the number of individuals capable of supporting missions. On the demand-side, GHE planners can leverage the playbooks and SEPs to socialize and promote the full menu of medical functional areas available for exchange with internal and external stakeholders, thereby increasing the demand signal for military health system capabilities from embassies and partners. Despite the successful debut, there is considerable room for improvement. The DOTMLPF-P capability assessments were underutilized during all three missions. Ideally, a robust DOTMLPF-P assessment would occur in advance of the engagement to determine the most applicable SEP for each exchange. However, in most cases the current state of the partner capability was not well understood prior to the engagement. In practice, despite the known benefits, CCMDs and Service Components are often reluctant or unable to allocate resources for a medical planner to conduct a proper assessment during an initial planning conference. Without the DOTMLPF-P assessment, subject matter experts were forced to estimate, often erroneously, the appropriate level of information to exchange with the partner. Another significant challenge is to determine who will develop the Joint Playbooks and SEPs. The Office of the Secretary of Defense for Health Affairs is positioned to lead stakeholders in Joint Playbook and associated SEPs development. Service training centers, such as the U.S. Army Medical Department Center and School and the U.S. Air Force School of Aerospace Medicine, may be ideal locations to leverage existing knowledge, regional and functional expertise, and CCMD inputs to generate Joint Playbooks and SEPs. After completion, maintaining, updating, and refining the products will require manpower and resources. Who will be responsible for version control and periodic updates? Where will the repository be housed? The Uniformed Services University (USU) Center for Global Health Engagement may fulfill this role in the future. But until the responsibility is codified, the products will largely depend on the dedication of, and dissemination by, GHE champions attempting to fill the existing capability gap. Guidance and direction provided by the Joint Staff Surgeon, with support from the Services and USU, is a necessary and feasible solution to developing, maintaining and updating the playbooks and associated SEPs for our Service personnel responsible for implementing GHE policy. Finally, playbooks and SEPs implementation should be led by qualified personnel. All too often, GHE missions are tasked to individuals based on proximity or availability rather than expertise and merit. The U.S. Air Force designates qualified professionals as International Health Specialists (IHS) and the U.S. Navy calls a similarly skilled cadre Global Health Specialists (GHS). While there is no comparable U.S. Army Additional Skill Identifier (ASI), Service leaders should, at a minimum, select individuals with the following attributes: (1) subject matter and training expertise; (2) operational experience; and (3) cultural agility. GHE practitioners should be competent enough to leverage the playbooks and associated SEPs in conjunction with their own expertise to execute missions that align with DoD and partner objectives. CONCLUSION When properly executed, GHE activities guided by SEPs advance partner nation medical competencies and capabilities with potentially powerful downstream strategic benefits; like enhancing partner infrastructure, interoperability, and access – each of which are important factors in U.S. national security. Playbooks guide the multi-year engagements leading to the development of specified partner capability over time. SEPs are the programs of instruction that incrementally build the knowledge, skills, and abilities toward that capability. Further, DoD policy defines and communicates the strategic requirement for GHE to support National Security Strategy objectives and goals. However, the DoD must improve how it tactically aligns, synchronizes, and executes GHE in support of these goals. The National Defense and Authorization Act 2017 (NDAA 2017) tasks the DoD to more fully leverage cross-Department and Joint Force approaches to improve efficiency, effectiveness, and reach. Playbooks and SEPs are valid tactical tools that meet the intent of the NDAA 2017, enable the Joint Force to implement the GHE Policy and assist in achieving National Security Strategy objectives. Leveraging the standardized, systematic, and longitudinal approach grounded in the Military Health Systems’ Joint capabilities and functional areas has clear advantages. Playbooks and SEPs offer U.S. planners, trainers, and practitioners a quality resource for GHE execution. The products provide GHE practitioners and partner nation participants with a means for implementation across various ways to achieve the desired ends as outlined in the CCMD theater campaign plan and National Security Strategy objectives. By aligning tactics with strategy, playbooks and SEPs help realize Albert Einstein’s three rules of work, “Out of clutter, find simplicity. From discord, find harmony. In the middle of difficulty lies opportunity.” Acknowledgements The authors are grateful for the critical comments provided by CAPT Anthony Battaglia, Mr. Brad Cogswell, Lt Col Elizabeth Erickson, and CDR Tammy Servies. References 1 US Department of Defense Instruction 2000.30 , Global Health Engagement Activities. Available at https://fas.org/irp/doddir/dod/i2000_30.pdf; accessed July 12, 2017. 2 Providence BT , Licina D, Leiendecker A: Increasing partner-nation capacity through global health engagement . JFQ 2017 ; 87 : 64 – 8 . Google Scholar OpenURL Placeholder Text WorldCat 3 US Department of Defense Joint Publication 4-02 , Joint Health Services. Available at http://www.jcs.mil/Portals/36/Documents/Doctrine/pubs/jp4_02.pdf; accessed December 11, 2017. 4 Cullison TR , Beadling CW, Erickson E: Global health engagement: a military medicine core competency . JFQ 2016 ; 80 : 54 – 61 . Google Scholar OpenURL Placeholder Text WorldCat 5 The Sphere Project, Humanitarian Charter and Minimum Standards in Humanitarian Response, 2011 edition. Available at http://www.spherehandbook.org/; accessed May 28, 2018. 6 Ramirez CC. “Chilean Armed Forces Join Peacekeeping Mission in Central African Republic.” Dialogo Americas, Dialogo Digital Military Magazine. Available at dialogo-americas.com/en/articles/chilean-armed-forces-join-peacekeeping-mission-central-african-republic; accessed February 26, 2016. Author notes The views expressed in this article are those of the authors and do not reflect the official policy or position of the U.S. Army Medical Department, Department of the Army, DoD, or the U.S. Government. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2018.
TI - Global Health Engagement Playbooks: Aligning Tactics with Strategy Using Standardized Engagement Packages
JF - Military Medicine
DO - 10.1093/milmed/usy132
DA - 2018-09-01
UR - https://www.deepdyve.com/lp/oxford-university-press/global-health-engagement-playbooks-aligning-tactics-with-strategy-8lL3Jf15FF
SP - 181
EP - 183
VL - 183
IS - 9-10
DP - DeepDyve
ER -